RESET Alcohol – General Support (December 2021)

Note: This page summarizes the rationale behind a GiveWell grant recommendation to RESET Alcohol Initiative. RESET Alcohol Initiative staff reviewed this page prior to publication.

Published: November 2022

The organizations

RESET Alcohol aims to reduce alcohol-related harm by assisting governments in adopting evidence-based policies for reducing alcohol consumption. Vital Strategies will coordinate the initiative. Key partners include:1

• Vital Strategies
• Movendi International
• The Tobacco Economics Team, based at the University of Illinois Chicago
• Global Alcohol Policy Alliance (GAPA)
• The Non-Communicable Disease (NCD) Alliance
• The World Health Organization (WHO)

This grant will be administered by Vital Strategies. Vital Strategies will then regrant funding to members of the consortium and other recipients.2

Vital Strategies is a public health organization of approximately 200 employees with an annual budget of approximately $120 million.3 Its previous work has included programs on tobacco policy, food policy, and road traffic safety as part of a coalition funded by Bloomberg Philanthropies.4

For more information on each of the partners and their roles in the initiative, see this proposal.

The grant

Activities

With this grant, RESET Alcohol will primarily work in four LMICs, selected on the basis of the estimated burden of harm from alcohol consumption and an assessment of the achievability of regulatory change.5 The grant also includes funding for a small grants program to respond to opportunities that arise outside the selected focus countries.6

This grant covers costs for three years.7

The primary objective of this grant is to achieve policy change (primarily increases in taxation, but also advertising and availability restrictions). Secondary objectives are to strengthen the capacity of country governments to develop and pass policies, monitor the impact of policies, enforce policies, and communicate to the public about the harms of alcohol.8

RESET Alcohol believes it is unlikely that adoption of a new tax policy will be achievable within three years. However, in each of its focus countries, it aims to formally introduce a tax policy proposal to the relevant decision-making entity within three years and enact at least one non-tax policy.9

High-level milestones in each country are:

• By the end of the first year: have engaged with the government on the planning of enhanced alcohol policies, including tax policies.
• By the end of the second year: specific policy proposals have been developed, and the policy enactment process is underway.
• By the end of the third year: at least one alcohol policy has been enacted, and a tax policy proposal has been formally introduced to relevant decision-makers.10

More details on the approach RESET Alcohol plans to take in the first year are available in this footnote.11

Budget

The anticipated allocation of grant funding is as follows:12

• Vital Strategies: $2.95 million13
• Embedded staff in government agencies in focus countries: $2.7 million
• Non-governmental organizations (NGOs) in focus countries: $2.7 million to both research and advocacy organizations
• Global partner organizations for technical and advocacy support: $2 million
• Government agencies in focus countries (e.g., Ministries of Health, national statistics agencies): $1.5 million
• Communication campaigns in focus countries: $1 million
• Technical consultants in focus countries: $0.5 million
• Small grants program outside of the four focus countries: $0.5 million
• Indirect costs: $1.2 million

Case for the grant and reservations

Why public health regulation

Alcohol policy is one of the promising areas we identified as part of GiveWell's work investigating giving opportunities to assist governments in LMICs with the design and implementation of effective public health regulations. We have prioritized work on public health regulation because of its ability to affect large numbers of people at relatively low cost via policy change.14 This grant page discusses the case for alcohol policy in isolation. For a comparative perspective, see this page.

Why we think alcohol policy is a promising focus area

We prioritized alcohol policy primarily because we understand that alcohol consumption causes a large burden of disease, and relatively little funding is dedicated to addressing that burden. We also believe that increasing taxes on alcohol is a fairly straightforward and evidence-based intervention which could help to address this problem.

In investigating alcohol policy, we considered the following three questions:

• How much harm is caused by alcohol consumption? The Institute for Health Metrics and Evaluation (IHME) estimates that 2.4 million people die from alcohol consumption each year.15 Roughly 75% of those deaths are in LMICs.16 We think this estimate is broadly credible, given the broader evidence base for harms caused by alcohol consumption. (more)
• How much philanthropic funding is spent on alcohol policy? Based on conversations with organizations and funders working on alcohol policy, we think alcohol is neglected relative to its burden. Our best guess is that under $5 million of annual philanthropic funding is spent on advocacy for alcohol control in LMICs. (more)
• How tractable is alcohol policy? We are uncertain about how tractable alcohol policy is relative to other public health regulation programs we considered. While there appears to be a set of evidence-based policies that could meaningfully reduce the burden, we expect that industry opposition will make improving alcohol policy somewhat less politically tractable than the other two areas where we've recommended grants: pesticide suicide prevention and reducing lead exposure. (more)

Based on the above, we expect that alcohol policy could absorb approximately $30 million more each year to have a similar spend per unit of harm to analogous areas like tobacco or road traffic safety.17 We take this as indicative that alcohol policy is neglected relative to the harm it causes.18

How much does alcohol consumption harm health?

IHME estimates that alcohol consumption leads to approximately 2.4 million deaths globally each year. In LMICs it estimates 1.9 million deaths (at an average age of 57) and 12.8 million total years lived with disability each year.19 This estimate is based on meta-analyses of 592 observational studies which estimate the effect of different levels of alcohol consumption on deaths from different causes. These effect sizes are combined with country-specific data on alcohol consumption and consumption patterns.20

In our view, the biggest limitation of the IHME estimate is that it is based on a large number of observational studies, rather than experimental or quasi-experimental evidence. We apply a downward adjustment to these estimates to account for the limitations of observational evidence.

We believe the broader evidence base, which is not included in IHME's Global Burden of Disease (GBD) review of observational studies, lends additional support to the conclusion that alcohol consumption causes substantial mortality:

• Multiple, uncorrelated strands of evidence not included in the GBD estimates (quasi-experimental studies on mortality outcomes,21 randomized controlled trials (RCTs) on biomarker outcomes22 ) lend additional support to alcohol consumption causing harm.
• Mendelian studies appear to call into question the potential protective effects of low levels of alcohol consumption (estimates of these protective effects are included in the GBD estimate).23
• The WHO estimates there are 3 million deaths from alcohol each year.24 Our understanding is that the WHO reaches that estimate using a different methodology from IHME (which we have not reviewed).25

We also note that at least some studies on the harms of alcohol consumption have been funded by the alcohol industry. We do not know whether GBD estimates systematically exclude these studies.26 These studies may underestimate the harms from alcohol (or overstate its protective effects) because of funding bias, but we are unsure of how to adjust for this consideration.27

How much philanthropic funding is there for alcohol policy?

Based on conversations with organizations and funders working on alcohol policy, we think alcohol is neglected relative to its burden.28 Our best guess is that under $5 million annually is spent on advocacy for alcohol control in LMICs.29

By comparison, we believe that about $70 million is spent on tobacco control annually, and about $30 million is spent on policies to reduce road traffic injuries.30 Based on our estimates of the relative harms caused by alcohol, tobacco, and road traffic injuries, we estimate that alcohol policy would need to receive an additional $30 million per year in order to reach the same spending level relative to harm as tobacco or road traffic injuries.31 We estimate that tobacco policy and road traffic safety receive approximately 10 times as much spending as alcohol relative to their burdens of disease.32

What are opportunities to make progress?

We think there is a set of interventions which are likely to be effective in reducing the burden of alcohol consumption. We think the intervention with the largest effect size and the strongest evidence is increasing alcohol taxation. However, compared to pesticide suicide (another area we have made grants in), the effect sizes of the most promising interventions appear modest.

We also expect that country adoption of more stringent alcohol regulations may be somewhat harder to make progress on than pesticide suicide and lead exposure due to direct opposition from the alcohol industry and a potential lack of public support in some countries.

Are there evidence-based solutions?

We briefly reviewed the evidence for three policies that the WHO calls "best buys:"33 taxation, restrictions on alcohol availability, and advertising restrictions. We also reviewed the evidence for drunk-driving countermeasures. We reviewed this evidence at a shallower level of depth than we typically do for grants to organizations directly delivering a specific intervention because the direct evidence on the effectiveness of interventions comprises a relatively smaller proportion of our rationale for making this grant.

Below, we share our initial views on these four approaches. We see them as indicative of the promisingness of the different interventions but not conclusive due to the challenges of precisely defining the specific policies in question (e.g. size of tax increase or stringency of availability restriction).

Type of Policy	Policy Details	Headline effect on annual alcohol deaths
Alcohol tax	10% price increase	~5%
Restrictions on alcohol availability	Reducing days of sale (by 1 weekend day), reducing hours of sale (no late-night hours), and raising minimum legal drinking age (by 3 years)	~2%
Restrictions on advertising	Partial ban on advertising	~2%
Drunk-driving countermeasures	Sobriety checkpoints	~0.5%

We adjust headline effect sizes for a number of factors, including the strength of evidence, how likely declines in consumption are to affect heavy drinkers, and how reliably we would guess interventions are enforced. Our brief review of the evidence base is available here, and disaggregated adjustments we applied to headline effect sizes are available here.

Our broad takeaways are:

• Within alcohol policies, taxation seems like the approach with the strongest evidence base and the largest likely effect on consumption.
• The effect size (as a proportion of total burden) seems likely to be substantially smaller for alcohol regulations than interventions to reduce pesticide suicide.34

We are unsure whether thinking narrowly in terms of specific policy successes might be an incomplete approach to reducing the burden of disease from alcohol consumption. For example, it seems likely that alcohol consumption is largely driven by long-term social norms. In assessing this grant, we focused on specific policy changes and effect sizes from the literature, but we wouldn't be surprised if we changed our approach in the future to more explicitly account for longer-term effects through norm changes.

Political tractability?

We're uncertain how tractable contributing to policy change will be. We note that:

• Several people with relevant expertise in alcohol or tobacco policy told us they expected alcohol policy to be difficult to make progress on due to opposition from the alcohol industry.35
• Taxes may be particularly challenging. Our understanding is that, in the field of tobacco control (which we take to be somewhat analogous to alcohol policy), there has been limited progress on increasing taxes relative to other interventions, although progress on taxation accelerated between 2016 and 2018.36

On the other hand:

• Countries appear to have made progress on reducing alcohol consumption. For example, a WHO report highlights alcohol policy in Russia as a success story. According to the report, between 2003 and 2016, alcohol consumption declined by 43%, alcohol poisoning mortality declined by about 75%, and mortality due to liver disease declined by about 23%.37 In this time period, a number of alcohol control measures were introduced, including a 50% increase in tax on ethyl alcohol in 2005.38 The report does not attempt to rigorously establish causality or disaggregate the effects of different policies.39 It is therefore possible that the declines in consumption were due to some factor other than regulation. However, given that the large declines in consumption and alcohol-related mortality coincided with a period of intense regulation, we take this as indicative that it is feasible for countries to substantially reduce alcohol consumption and mortality.
• A number of countries implemented additional alcohol regulations in response to the COVID-19 pandemic, suggesting some political will for alcohol policy (although other countries loosened alcohol regulations).40
• Vital Strategies plans to prioritize engaging with countries in which the governments have expressed an interest in advancing new policies.41

Overall, we are quite uncertain how feasible it will be to effectively increase alcohol regulations. Qualitatively, we expect it to be more challenging to advance alcohol control policies than pesticide regulation or lead exposure policies.

What are potential downsides/negative and offsetting factors?

Potential downsides of policies to reduce alcohol consumption include:

• Lost enjoyment from alcohol consumption. If people derive some pleasure from drinking alcohol, then policies to reduce alcohol consumption may cause some negative welfare impact which should be netted off the potential benefits. We apply a fairly subjective 10% downward adjustment to our cost-effectiveness analysis to account for this consideration.42
• Potential substitution of illicit alcohol. If higher taxes or more stringent regulations increase the cost of regulated alcohol, people may substitute unregulated alcohol, which may be more harmful to their health. We have not investigated this question in depth.
• Potential regressiveness of alcohol taxes. If lower-income people spend a higher proportion of their income on alcohol, then it is possible that alcohol taxes could be regressive. We have not investigated this question in depth.

Why this giving opportunity within alcohol control?

Vital Strategies will coordinate the initiative and has been our main point of contact in developing the proposal. We think Vital Strategies is a strong organization with experience coordinating large-scale public health advocacy campaigns.

• Vital Strategies has a track record of working on analogous large-scale advocacy campaigns through its work funded by Bloomberg Philanthropies, which includes tobacco policy, food policy, and road traffic safety.43
• We spoke with several people familiar with Vital Strategies' work. We got a positive impression of Vital Strategies' past work from these conversations.44
• We spoke to Vital Strategies and reviewed several documented case studies of successful policy change (tax increases and other control policies in Ukraine, Chad, and Indonesia; road safety improvements in Sao Paulo). We found the case studies believable examples of Vital Strategies contributing to large-scale policy changes in areas analogous to alcohol policy. Vital Strategies also told us that between 2018 and 2020, it contributed to 43 policy changes across 12 countries (we have not checked that claim).45

We note that Vital Strategies does not have substantial direct experience working in alcohol policy. We expect GAPA and Movendi International, two members of the initiative, will contribute experience working in alcohol policy.

Risks and reservations

• This grant is more expensive on a per-country basis than previous grants we have made in public health regulation. This cost is primarily driven by the consortium having more specialized expertise and working on a more diverse set of activities than previous grants we've recommended in public health regulation.46
• This is a relatively early-stage grant. For a grant this size, we know unusually little about how successful the work will be. For example, RESET Alcohol has not yet finalized its selection of countries. This makes assessing cost-effectiveness challenging.
• We expect reducing harm from alcohol consumption will be challenging to make progress on because of potential opposition from the industry and because of the (relatively) modest effect size of interventions. (more)
• A large part of the case for this grant is the very high estimated burden of disease from alcohol consumption. While we are confident that alcohol causes substantial harm, the specific estimate is based on a large number of observational studies which we have not reviewed in depth. (more)

Cost-effectiveness

We completed a back-of-the-envelope calculation on RESET Alcohol's cost-effectiveness. That rough estimate suggested RESET Alcohol's work may be more cost-effective than our threshold for recommending funding. At the time we recommended this grant, we were primarily looking to recommend grants that we estimated were 8x cash or higher, and were willing to consider recommending a limited amount of funding to grants that were between 5x and 8x cash.

We completed this back-of-the-envelope calculation to discipline ourselves to make our assumptions explicit and quantitatively weigh different considerations. However, the estimate relies on a number of difficult best-guess assumptions and judgment calls about modeling structure. It therefore contains less information value than cost-effectiveness estimates for our top charities, which limits its comparability. (In general, there are limitations to all of our cost-effectiveness analyses, and we believe they should be taken as rough and directional abstractions, due to the significant uncertainty around them.)

Our back-of-the-envelope estimate is available here. We outline some of the more important inputs below.

Key inputs and parameters in our back-of-the-envelope cost-effectiveness analysis:

• Scope of modeling. We expect the majority of RESET Alcohol's work will focus on four priority countries, which have not yet been finalized. We modeled the impact of RESET Alcohol's work in a weighted average of the 19 LMICs which IHME estimates to have more than 5,000 deaths each year from alcohol consumption. We excluded a number of countries from this analysis for reasons in this footnote.47 We did not explicitly model the impact of RESET Alcohol's small grants program. We inflate the modeled benefits from the country-focused work to account for the proportion of the budget which we expect to be spent on unmodelled benefits. This implicitly assumes unmodelled activities are equally cost-effective to RESET Alcohol's country-focused work.
• Costs. We include the full cost of the grant, $15 million. While this grant is intended to cover three years of work, we included an upward adjustment to account for the expected costs over five years to be consistent with how we were thinking about the chance of policy impact. We apply a subjective downward adjustment to benefits (5%) to account for potential costs to governments implementing regulations.
• Baseline disease burden. We used IHME estimates for alcohol burden as a baseline and made a number of adjustments: (i) a subjective downward adjustment (0.8x) to account for limitations of the evidence base, (ii) an upward adjustment (1-2x depending on the country) to account for projected growth in alcohol consumption over time, (iii) a downward adjustment (0.7-1x depending on the country) to strip out IHME estimates of unrecorded and/or illicit alcohol consumption.
• Effectiveness of regulations. We included our best guess of the reduction in deaths from alcohol we would expect from tax increases, availability restrictions, drunk-driving countermeasures, and advertising restrictions. We made various adjustments to the headline effect sizes of studies to account for limitations of the evidence base (more above). These include adjustments for regulations being imperfectly enforced and the possibility that they disproportionately reduce consumption in moderate drinkers (who we expect have a lower burden of disease per unit of consumption). More details above.
• Increase in chance that each policy is passed. Our best guess is that within five years, RESET Alcohol's work will increase the chance of a 10% increase in tax by 35%, and increase the chance of other policies passing by 45%. Conceptually, this estimate is intended to include the possibility of a larger or smaller increase in tax. These estimates are necessarily subjective, and we do not feel confident they are well calibrated.48
• For how many years do we model the benefits? We model the benefits of a policy as persisting for 10 years. This assumption is very uncertain and subjective, which makes it difficult to compare the cost-effectiveness of this grant with that of GiveWell's top charities. We selected 10 years as a reasonable-seeming default for evaluating the impact of implementing regulations in general and did not meaningfully update from this default.
• Moral weights. We compared the benefit of preventing deaths at different ages using GiveWell's moral weights and IHME estimates of the age distribution of deaths from alcohol consumption.

There were a number of considerations we did not investigate fully because we thought it was unlikely they would change our decision to recommend this grant. We include rough guesses about how deeper investigation might affect the cost-effectiveness of the grant here. Those considerations include:

• Morbidity from alcohol consumption (+19%)
• Productivity benefit from reduced alcohol consumption (+10%)
• Reduction in crime and antisocial behavior (+10%)
• Reduced treatment costs from drinkers (+5%)
• Reduction in drinking during pregnancy improving birth outcomes (+5%)
• Net enjoyment of alcohol for moderate drinkers (-10%)
• The potential increase or decrease in informal/unrecorded consumption from additional regulation (-5%)
• Government costs of enforcing regulation (-5%)

We also did a breakeven analysis to give a more intuitive sense of what would need to happen for this grant to be cost-effective. Based on this analysis, we estimate that increasing taxation by 10% of price in one of the four countries RESET Alcohol plans to focus on (weighted by the likelihood of RESET Alcohol entering each country) would be sufficient to make a five-year program look cost-effective relative to alternative uses of GiveWell funding.49

Plan for follow-up and major open questions

We plan to check in with Vital Strategies for an update on progress every three months.

We expect to decide whether to recommend a grant extension approximately two years after the initial grant is made. Our expectation is that RESET Alcohol's work will not have led to policy change at the time we consider a grant extension.

We expect our investigation at that time to be limited and based on the extent to which RESET Alcohol has successfully met its goal of developing specific policy actions and beginning the policy enactment process within two years.50 We are open to the possibility that the appropriate milestones will change after further planning.

We considered making a grant over a longer time period than three years, but thought that the costs to delaying additional funding were relatively low and the information gained from delaying the decision was moderate.

Open questions about the grant we plan to follow up on include:

• How are RESET Alcohol's activities progressing against planned milestones?
• Have RESET Alcohol's activities led to changes in alcohol policy in any of the countries it works in?
• How many deaths do we expect were prevented by policy changes RESET Alcohol contributed to? Are there promising opportunities to get more information on this estimate?

Other open questions we may investigate further:

• Would deeper or broader review of the evidence related to the burden of disease from alcohol meaningfully change our conclusions?
• Would deeper or broader review of the evidence related to the effect of alcohol policy interventions meaningfully change our conclusions?
• What is an appropriate assumption for the number of years of benefit to count for a policy change?

We are not yet sure when we will revisit these questions. We would not be surprised if we renewed this grant without doing more work to address the open questions.

Forecasts

Prediction	Resolution date	Credence
Grant recommendations
We recommend another grant to RESET Alcohol	July 1, 2025	85%
We have recommended over $50m in grants to RESET Alcohol	July 1, 2027	40%
Process
At least three of the four selected countries are "on track" in Year 151	July 1, 2023	50%
At least two of the four selected countries are "on track" in Year 252	July 1, 2024	50%
Policy impact
We estimate that RESET Alcohol has not contributed to any policy changes in its focus countries	July 1, 2025	30%
We assign a weight of over 50% for RESET Alcohol's contribution to a policy change in at least one focus country	July 1, 2025	70%
We assign a weight of over 50% for RESET Alcohol's contribution to a policy change in at least two focus countries	July 1, 2025	50%
We assign a weight of over 50% for RESET Alcohol's contribution to a policy change in at least three focus countries	July 1, 2025	30%
RESET Alcohol has contributed (>50% weight) to a proposal introduced to the government to increase tax on alcohol by at least 5% of price in at least one focus country	July 1, 2025	65%
RESET Alcohol has contributed to an increase in tax on alcohol by at least 5% of price in at least one focus country	July 1, 2025	40%
Ex-post cost-effectiveness
We estimate that RESET Alcohol's cost-effectiveness based on its direct contributions to policy changes was <1x as cost-effective as cash transfers	July 1, 2025	35%
We estimate that RESET Alcohol's cost-effectiveness based on its direct contributions to policy changes was 1-10x as cost-effective as cash transfers	July 1, 2025	20%
We estimate that RESET Alcohol's cost-effectiveness based on its direct contributions to policy changes was 10-20x as cost-effective as cash transfers	July 1, 2025	25%
We estimate that RESET Alcohol's cost-effectiveness based on its direct contributions to policy changes was >20x as cost-effective as cash transfers	July 1, 2025	20%

Our process

• Alcohol policy fits into GiveWell's work on public health regulation. We prioritized alcohol policy after comparing it on the basis of importance, tractability, and neglectedness with other areas we could recommend funding for.
  • We reviewed relevant evidence on the harms caused by alcohol consumption.
  • We reviewed relevant evidence on the extent to which alcohol policies reduce mortality.
  • We spoke with relevant organizations in the space and estimated how much funding was spent on alcohol policy.
• In January 2021, we recommended a grant of $100,000 to develop a proposal for a consortium to work on alcohol policy. To assess that proposal, we:
  • Built a back-of-the-envelope cost-effectiveness analysis.
  • Spoke with people who had worked closely with Vital Strategies and briefly reviewed some case studies of Vital Strategies contributing to policy change.
  • Spoke with people living in countries in which Vital Strategies might work to understand the policy landscape.
  • Had regular conversations with Vital Strategies to align on the strategic focus of the initiative.
  • Investigated the extent to which the enjoyment of alcohol should offset the health benefits.

Sources

Document	Source
Christensen et al. 2018	Source (archive)
ERAB: The European Foundation for Alcohol Research, "About ERAB"	Source (archive)
GBD 2016 Alcohol Collaborators 2018	Source (archive)
GiveWell, "Centre for Pesticide Suicide Prevention — General Support (January 2021)"	Source
GiveWell, "Public Health Regulation Update," 2021	Source
GiveWell, "Pure Earth — Support for Reducing Lead Exposure in Low- and Middle-Income Countries," 2022	Source
GiveWell, "Vital Strategies — Support for a Consortium on Alcohol Control Policy," 2021	Source
GiveWell, Alcohol policy evidence review write-up, 2022	Source
GiveWell, CEA_CPSP past impact, 2021	Source
GiveWell, Crowdedness calculations for public health regulation	Source
GiveWell, Probability of success: alcohol policy	Source
GiveWell, Public health regulation prioritization, 2021	Source
GiveWell, Vital Strategies BOTEC_Breakeven, 2022	Source
GiveWell, Vital Strategies BOTEC, 2022	Source
GiveWell, Weighing alcohol enjoyment, 2022	Source
GiveWell's non-verbatim summary of a conversation with Kristina Sperkova, April 4, 2019	Source
GiveWell's non-verbatim summary of a conversation with Kristina Sperkova, March 28, 2019	Source
GiveWell's non-verbatim summary of a conversation with Moses Waweru, October 7, 2021	Source
GiveWell's non-verbatim summary of a conversation with Øystein Bakke, March 21, 2019	Source
GiveWell's non-verbatim summary of a conversation with Professor Sally Casswell, April 1, 2019	Source
GiveWell's non-verbatim summary of a conversation with Vital Strategies, August 26, 2020	Source
Roodman, "The impacts of alcohol taxes: a replication review," 2015	Source (archive)
Shaaya, Al-Khazaali, and Arora 2017	Source
Smith and Ebrahim 2008	Source
Tasnim et al. 2020	Source
Vital Strategies, "Our Work"	Source (archive)
Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021	Source
Vital Strategies, Case study – Tobacco Taxation in Chad	Unpublished
Vital Strategies, Road safety policies and population coverage	Unpublished
Vital Strategies, Tax disclosure form, 2019	Source (archive)
Vital Strategies, Ukraine 2007-2016: A case study of tobacco control cooperation and success	Unpublished
Vital Strategies, Vital Strategies’ role in global initiative coordination – example of Bloomberg Philanthropies Initiative for Global Road Safety	Source
Vos et al. 2020	Source
World Health Organization, "Alcohol"	Source (archive)
World Health Organization, "Hypertension"	Source (archive)
World Health Organization, "Saving lives, spending less: the case for investing in noncommunicable diseases," 2017	Source (archive)
World Health Organization, Alcohol policy impact case study, 2019	Source (archive)
World Health Organization, WHO report on the global tobacco epidemic 2021: addressing new and emerging products, 2021	Source (archive)

• 1

  "Vital Strategies will coordinate the Initiative as well as provide technical assistance in key areas. Key global partners are Movendi International, University of Illinois Chicago (UIC), Global Alcohol Policy Alliance, the NCD Alliance, and WHO." Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 3.
  

• 2

  See Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, "Subgrants," p. 24.
  

• 3

  See page 1, line 18 for total expenses ($117,229,094) and page 1, line 5 for the number of individuals employed in 2019 (212) on Vital Strategies' 2019 tax disclosure form.
  

• 4

  See here for an overview of Vital Strategies' work.
  

• 5

  "We propose to include 4 “focus” countries in the Initiative receiving intensive support, and up to 7 additional countries receiving targeted grants for more limited support. Prioritization of countries for approach and engagement will be guided by the following considerations:
  - Significant alcohol-related national mortality, morbidity, and social burdens;
  - Clear policy opportunities (existing policy on which to build; political support/evident government interest; etc.) for alcohol tax
  increases and at least one other priority alcohol policy intervention;
  - Previous or current participation in other alcohol or related health and development initiatives (e.g., tobacco control, road safety)
  in at least some focus countries;
  - Robust civil society community and readiness for engagement on relevant alcohol policy issues"
  Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, pp. 2-3.

• 6

  "Accordingly, as part of the APHDI, we propose establishing a small grants program to support such activities in up to 7 additional countries. The contours of such a program would be:
  - A call for applications from either government agencies or nongovernmental/civil society organizations;
  - Grant awards of up to $100K for projects of up to 12 months
  - Funds to support consultants, events, publications, trainings, etc.;
  - Clear articulation in applications of the policy opportunity that could be advanced and how the activities under the grant will contribute to the policy objectives;
  - Initiative partners would provide limited technical assistance, as requested by applicants;
  Vital Strategies has experience administering such grant programs. For example, the Bloomberg Philanthropies Data for Health Initiative comprises 25 focus countries with intensive engagement, and also includes a Global Grants Program that extends more limited support to over 20 additional countries, with considerable success: https://www.d4hglobalgrantsprogram.org. A targeted grants program also exists for Bloomberg Philanthropies’ global tobacco control and road safety initiatives."
  Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 22.
  

• 7

  "We propose a 3-year timeline for the Initiative, starting with a four-month startup period to approach and formalize agreements with participating country governments and local civil society and research partners." Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 1.
  

• 8

  "The primary objective of the Initiative is to assist countries to advance and adopt specific new alcohol policies; however critical secondary objectives are to strengthen the capacity of countries to establish sustained public health programs related to alcohol, including ongoing policy development, policy implementation and enforcement, data collection and monitoring, and public communication." Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 2.
  

• 9
  • "We define success for the Initiative as governments significantly advancing new policies for increasing alcohol taxes as
    well as enacting one or more additional high-impact policy interventions around alcohol availability regulation or marketing restrictions." Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 1.
  • "The primary objective is policy adoption – in the case of tax increases, in the span of a 3-year initiative, it may be unrealistic to expect final adoption of a new tax policy; however, we would expect significant progress toward this objective, namely formal introduction/tabling of the policy proposal to the relevant decision-making entity." Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 9.

• 10

  "By the end of the first year of a country’s engagement, partners will be assisting the government with economic assessments and planning of fiscal policies and other new or enhanced policy interventions. In tandem, partners will assist civil society and government to chart an advocacy plan. During the second year, we anticipate specific legislative, regulatory, or executive actions to be developed and the policy enactment process underway, with supportive analytic products, advocacy efforts, media campaigns, and other activities. By the end of year 3 we would anticipate seeing significant progress on the tax policy process and enactment of at least one other impactful alcohol policy." Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 3.
  

• 11

  "The work in each country will be tailored to the context and needs of each in dialogue with local partners. For the first year, Initiative partners coordinated by Vital Strategies will focus efforts on:
  - Conducting a detailed baseline situational analysis of the policy and stakeholder landscape as well as of the alcohol industry practices and influence;
  - Developing an overall strategy to enact policy change on the basis of the situational analysis;
  - Formalizing partnerships with government agencies, local research institutions, and civil society organizations;
  - Enhancing government, research institutions, and civil society capacity in alcohol policy;
  - Enhancing data collection systems and sustained capacity of government to collect, analyze and use data for policy and program planning;
  - Engaging media around alcohol generally as a public health and development issue and on specific policy issues." Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 3.
  

• 12

  See Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, "Budget Summary," p. 24 for a full breakdown of the grant allocation.
  

• 13According to the budget summary in Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 24, for Vital Strategies, $2.2 million is for personnel and $0.75 million is for travel, rent, equipment, and supplies.
  
• 14

  See GiveWell's Public Health Regulation Update for more information.

• 15

  See sheet "Public Health Regulation Prioritization": 1,885,317 (number of deaths in LMICs) + 555,459 (number of deaths in high-income countries) = 2,440,776.

• 16

  The total number of deaths in LMICs in 2019 was 1,885,317 and the total number of deaths in all countries was 2,440,776 (See sheet "Public Health Regulation Prioritization"). 1,885,317/2,440,776= ~77%.

• 17See "Public Health Regulation Prioritization," column "Additional annual spend to equal spend per unit of burden for tobacco."
  
• 18

  See "Public Health Regulation Prioritization."
  

• 19

  See "Public Health Regulation Prioritization," "Alcohol use" section.

• 20

  "For our relative risk estimates, we extracted 3992 relative risk estimates across 592 studies. These relative risk estimates corresponded to a combined study population of 28 million individuals and 649 000 registered cases of respective outcomes. We list all the included data sources in appendix 1 (pp 52–140)."

  "To estimate exposure, we combined estimates of population-level alcohol stock and individual-level alcohol consumption to produce standard drinks consumed daily among current drinkers and current drinker prevalence, within a specific location, year, age group, and sex. We started by estimating population-level alcohol stock in litres per capita from sales data, individual-level estimates of the prevalence of current drinkers and abstainers from survey data, and individual-level estimates of the amount of alcohol consumed in grams per day from survey data. Then, for a given location and year, we rescaled age-specific and sex-specific estimates of individual-level consumption so that they aggregated to the estimates of population-level consumption. When surveys reported amount consumed in terms of beverage types, we converted these data into grams of pure ethanol using density equations and assumptions of the average alcohol content by drink type (appendix 1, p 50). Finally, we rescaled estimates of current drinking and abstention so that, within a given location, year, age group, and sex, the two estimates summed to one."
  GBD 2016 Alcohol Collaborators 2018
  

• 21

  Open Philanthropy commissioned David Roodman to conduct a replication review of quasi-experimental evidence linking alcohol prices and alcohol-related mortality in the USA. The review concluded that the best-conducted studies suggested that price increases led to reduced consumption and reductions in alcohol-related mortality. It suggests a price increase of 1% may result in a ~.0.5% reduction in alcohol consumption, and a 1-3% decrease in alcohol-related deaths. However, the definition of alcohol-related deaths focuses primarily on cirrhosis, which comprises only about 12% of the disease burden estimated in the Global Burden of Disease.

  ("Few of the underlying studies attain high-quality causal identification as that term is meant today in economics, exploiting randomized treatment or strong natural experiments. Here, I focus on the minority of studies that do use natural experiments—sudden changes in alcohol taxation in certain states or countries.

  Superficially, the high-quality studies contradict each other. Alcohol tax cuts apparently did not increase problem drinking in Denmark or Hong Kong, for instance, but did in Finland and Switzerland. Yet the overall pattern across the quasi-experiment studies is that the larger the experiment—the larger the price change—the clearer the effects. The 7% tax hike in Alaska on October 1, 2002, and the 18% cut in Finland on March 1, 2004, are leading examples.2 The simplest and most plausible explanation for the “null” results in other contexts is that their natural experiments were too small to produce unambiguous consequences.

  Overall, in my view, the preponderance of the evidence says that higher prices do correlate with less drinking and lower incidence of problems such as cirrhosis deaths. And, as I elaborate, I see little reason to doubt the obvious explanation: higher prices cause less drinking. A rough rule of thumb is that each 1% increase in alcohol price reduces drinking by 0.5% (Nelson 2013, as discussed below). And, extrapolating from some of the most powerful studies, I estimate an even larger impact on the death rate from alcohol caused-diseases: 1–3% within months. By extension, a 10% price increase would cut the death rate 9–25%. For the US in 2010 (author’s calculations, based on WHO), this represents 2,000–6,000 averted deaths/year.

  How much a tax-induced price increase would affect violence and traffic deaths is harder to establish from the available studies. The clearest impacts in the literature have indeed been on the death rate from cirrhosis, in part because drinking is the primary cause, in part because heavy drinkers are presumably most sensitive to price, in part because the impact can be nearly immediate, making for easier statistical detection. (Although cirrhosis is a chronic disease, it is progressive, so that a sudden increase in drinking can speed death among those in whom the disease is most advanced. Seeley 1960.) Impacts on crime, suicides, and risky sexual behavior have been reported, but have not yet been demonstrated through strong natural experiment–based studies. And even the link to alcohol-caused diseases is less clear in the long term. It is difficult to pin down longterm impacts because tax changes mix with many other influences over time. This matters particularly for alcohol, because unlike with smoking, many studies find moderate drinking to be healthy. If the death increase from discouraging moderate drinking only surfaces after decades, it will be missed in all the studies reviewed.") Roodman, "The impacts of alcohol taxes: a replication review," 2015, pp. 1-2.

  Cirrhosis accounts for ~12% of alcohol-related deaths in the GBD. See Vital Strategies BOTEC.

• 22

  There are a number of RCTs assessing the effect of alcohol consumption on biomarkers. For example, Tasnim et al. 2020 is a Cochrane review of RCTs (32 RCTs, 767 participants) on the effect of alcohol consumption on blood pressure and heart rate (two biomarkers associated with adverse health outcomes). It concludes that "alcohol decreases blood pressure initially (up to 12 hours after ingestion) and increases blood pressure after that. Alcohol consistently increases heart rate at all times within 24 hours of consumption." We have not reviewed this study in depth or systematically searched for RCTs on other biomarkers. See World Health Organization, "Hypertension" and Shaaya, Al-Khazaali, and Arora 2017.

• 23

  Mendelian randomized studies attempt to use genetic variation associated with alcohol consumption as an instrumental variable to obtain a causal estimate of the effect of alcohol consumption on various health outcomes. (See Smith and Ebrahim 2008). In theory (if the requirements of an instrumental variable are met), these studies would be less subject to confounding or reverse causation than observational studies.

  ("As well as the analogy with randomized controlled trials, Mendelian randomization can also be likened to instrumental variable approaches that have been heavily utilized in econometrics and social science. In this approach, the instrument is a variable that is related to the outcome only through its association with the modifiable exposure of interest. The instrument is not related to confounding factors, nor is its assessment biased in a manner that would generate a spurious association with the outcome. Furthermore the instrument will not be influenced by the development of the outcome (i.e., there will be no reverse causation). Figure 16-5 presents this basic schema, where the dotted line between genotype and the outcome provides an unconfounded and unbiased estimate of the causal association between the exposure that the genotype is proxying for and the outcome. The development of instrumental variable methods in econometrics, in particular, has led to a sophisticated range of statistical methods for estimating causal effects, and these have now been applied in Mendelian randomization studies (e.g., Davey Smith et al., 2005a, 2005b; Timpson et al., 2005). The parallels between Mendelian randomization and instrumental variable approaches are discussed in more detail elsewhere (Thomas and Conti, 2004; Didelez and Sheehan, 2007; Lawlor et al., 2007)." (Smith and Ebrahim 2008)

  Our impression is that this literature calls into question the protective effects of low levels of alcohol consumption which are estimated in observational studies (and netted off the GBD estimates).

  ("Additionally, some research suggests that low levels of alcohol consumption can have a protective effect on ischaemic heart disease, diabetes, and several other outcomes. This finding remains an open question, and recent studies have challenged this view by use of mendelian randomisation and meta-analyses." GBD 2016 Alcohol Collaborators 2018

  "However, my preliminary take on the epidemiological evidence is that the health benefits of moderate drinking are not certain—not as convincing, for instance, as the natural experiment–based tax impact studies featured in this review. Mendelian-randomized studies, which exploit genetic variation to construct natural experiments, have found no benefit (Holmes et al. 2014). Mendelian-randomized studies are not as reliable as conventional randomized trials (Thomas and Conti 2004). But they may supply the best evidence available since no randomized studies have been done on the question. So I think that on current evidence, Occam’s Razor favors the simple theory that the harm of drinking rises steadily with quantity at all levels. (Notably, this implies that moderate intake of alcohol, like moderate intake of many things, does at most modest harm, so the point is not to warn people off drinking at all.) The bottom line for the present inquiry is that, on net, alcohol tax increases are likely to save lives in the long run too." Roodman, "The impacts of alcohol taxes: a replication review," 2015, p. 2.)

• 24

  "Worldwide, 3 million deaths every year result from harmful use of alcohol," World Health Organization, "Alcohol".

• 25

  Email from Dr. Jurgen Rehm, unpublished, June 26, 2019.

• 26

  For example, Christensen et al. 2018 was funded by "The European Foundation for Alcohol Research," which is funded by an alcohol industry trade association: ERAB: The European Foundation for Alcohol Research. This study is not included in the GBD review, but we are unsure whether other studies funded by the alcohol industry are also excluded.

• 27

  Vos et al. 2020 suggests 5.4% of 386 observational studies on moderate drinking were funded by the alcohol industry and there was no evidence that the results systematically differed by funding source. However, eight of the authors of Vos et al. 2020 were employed by an institute which received funding from the alcohol industry, which leaves us uncertain how to interpret this finding and what we should believe about the potential effect of funding bias in the literature.

  • "Funding of research by industry in general can lead to sponsorship bias. The aim of the current study was to conduct an initial exploration of the impact of sponsorship bias in observational alcohol research by focusing on a broad spectrum of health outcomes. The purpose was to determine whether the outcome depended on funding source. We focused on moderate alcohol consumption and used meta-analyses that are the basis of several international alcohol guidelines. These meta-analyses included observational studies that investigated the association of alcohol consumption with 14 different health outcomes, including all-cause mortality, several cardiovascular diseases and cancers, dementia, and type 2 diabetes. Subgroup analyses and metaregressions were conducted to investigate the association between moderate alcohol consumption and the risk of different health outcomes, comparing findings of studies funded by the alcohol industry, ones not funded by the alcohol industry, and studies with an unknown funding source. A total of 386 observational studies were included. Twenty-one studies (5.4%) were funded by the alcohol industry, 309 studies (80.1%) were not funded by the alcohol industry, and for the remaining 56 studies (14.5%) the funding source was unknown. Subgroup analyses and metaregressions did not show an effect of funding source on the association between moderate alcohol intake and different health outcomes. In conclusion, only a small proportion of observational studies in meta-analyses, referred to by several international alcohol guidelines, are funded by the alcohol industry. Based on this selection of observational studies the association between moderate alcohol consumption and different health outcomes does not seem to be related to funding source." Vos et al. 2020.
  • "Author disclosures: MV, APMvS, TvW, MLJ, RMD, RJB, IdK, and AS were employed by the Dutch Beer Institute during the study and writing of the manuscript. This Institute is funded by Dutch Brewers, which is the trade organization of the 14 largest beer brewers in the Netherlands. EJMF reports no conflicts of interest." Vos et al. 2020.

• 28

  For example:

  • GiveWell's non-verbatim summary of a conversation with Kristina Sperkova, March 28, 2019, p. 4.
  • GiveWell's non-verbatim summary of a conversation with Kristina Sperkova, April 4, 2019
  • GiveWell's non-verbatim summary of a conversation with Øystein Bakke, March 21, 2019
  • GiveWell's non-verbatim summary of a conversation with Professor Sally Casswell, April 1, 2019

• 29"Our best guess is $3 million in total annual funding for alcohol control advocacy in LMICs, with a high-end guess of $5 million," GiveWell, Crowdedness calculations for public health regulation, p. 3.
  
• 30
  • "In October 2013, Open Philanthropy estimated that the majority of annual philanthropic spending to improve road traffic safety came from Bloomberg Philanthropies ($25 million) and the FIA Foundation ($7 million), totaling $32 million," GiveWell, Crowdedness calculations for public health regulation, p. 6.
  • "IHME estimates that tobacco control received between $60 and $90 million in external financing each year from 2015 to 2019, or $70 million per year on average." GiveWell, Crowdedness calculations for public health regulation, p. 7.

• 31

  See "Public Health Regulation Prioritization," column "Additional annual spend to equal spend per unit of burden for tobacco."

• 32

  See "Public Health Regulation Prioritization," column "Spend per unit of burden ($ million)."
  

• 33

  See the WHO's "Saving lives, spending less: the case for investing in noncommunicable diseases," 2017, p. 8.

• 34

  Our very uncertain best guesses are that:

  • An increase in taxation of 10% of the price will lead to a 2.6% decline in annual alcohol mortality (once we apply various adjustments to the headline results). See Vital Strategies BOTEC for calculations.
  • Regulations which the Centre for Pesticide Suicide Prevention contributed to in Nepal will reduce the annual number of pesticide suicides by 30%. (Annual deaths prevented (forecast) = 384; Annual pesticide suicides in Nepal = 1284; 384/1284 = ~30%)

• 35
  • We spoke with three people with experience in alcohol and tobacco policy advocacy off the record. They told us they expected making progress to be challenging due to opposition from the alcohol industry.
  • "Factors hindering the bill’s passage [in Kenya] include opposition from media and public opinion; lobbying by the alcohol industry for self-regulation and for changes to the act that would favor the industry (though the final law does not include many of those provisions); and the introduction of the unpopular Alcoblow, a breathalyzer instrument, during the same legislative season." GiveWell's non-verbatim summary of a conversation with Moses Waweru, October 7, 2021.

• 36
  • Conversation with Kelly Henning, unpublished, January 31, 2018
  • "Raising prices through taxation is the most effective way to reduce tobacco use and yet it remains the policy with the lowest population coverage. While a large increase in population coverage was observed between 2016 and 2018 (from 8% in 2016 to 13% in 2018), the proportion of the world’s population protected by taxes at best-practice level has since remained at 13%." World Health Organization, WHO report on the global tobacco epidemic 2021: addressing new and emerging products, 2021, p. 22.
  • See also "INCREASE IN THE WORLD POPULATION COVERED BY SELECTED TOBACCO CONTROL POLICIES, 2007* TO 2020" graph, World Health Organization, WHO report on the global tobacco epidemic 2021: addressing new and emerging products, 2021, p. 23.

• 37
  • "Following the pronounced peak in 2003, total alcohol consumption had decreased by 43% by 2016, with a substantial decline in spirits drinking (67%) and consumption of unrecorded alcohol (48%). Within the same period, consumption of lighter alcoholic beverages decreased slightly; wine drinking declined by about 8% and beer drinking by about 4%." World Health Organization, Alcohol policy impact case study, 2019, p. 8.
  • "Between 2003 and 2017 the most substantial drops were observed in alcohol poisoning mortality, with a decline of 73% in men and 78% in women. Mortality due to alcoholic psychoses dropped by 80% in men, while the overall numbers for women were too low to allow meaningful comparison over time. SDRs from alcoholic liver disease (alcoholic cirrhosis, hepatitis, fibrosis) increased between 1990 and 1995, followed by a mild decrease and a steep rise between 1998 and 2005; after that, there were strong fluctuations, with a marked downward trend over the last two years. Between 2003 and 2017 mortality due to alcoholic liver disease declined by 22% in men and 24% in women." World Health Organization, Alcohol policy impact case study, 2019, pp. 18-19.

• 38

  See Table 2 in World Health Organization, Alcohol policy impact case study, 2019, pp. 31-32.

• 39

  "These declines might also be attributable to the longterm effects of previous measures. Further analyses are therefore needed to differentiate the relative effects of single policy measures. Clearly, a measure such as a ban on alcohol advertising will act from its original implementation until it is revoked, producing a lasting effect and thus having an impact on all periods thereafter (assuming it is enforced with the same intensity). Other measures, such as tax increases and MUP, will weaken in their effectiveness over time on account of inflation, unless they are already adjusted for inflation in the initial law. All these considerations are necessary to draw a detailed picture of the impact of different alcohol control policy measures in the Russian Federation. However, this was beyond the scope of the present case study." World Health Organization, Alcohol policy impact case study, 2019, p. 29.

• 40

  The COVID-19 pandemic has prompted a variety of alcohol-related policy interventions by national governments. Some have instituted restrictions on sales, under the premises of either reducing health care system utilization (e.g., South Africa) or reducing risks (curfews, bar/restaurant closures, e.g., India; production limits, e.g., Mexico). In other cases, access to alcohol has been expanded via loosening of regulations around carryout or online sales. Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 5.

• 41

  "The criteria for identifying the set of countries to approach will be:

  • Burden of alcohol consumption and alcohol-related harms – reflecting the preventable burden targeted by the initiative, based on consumption rates and population size
  • Extant policy landscape in the country in key domains of tax, marketing, and availability and opportunities for enhancement.
  • Evidence and/or indications that government has interest in advancing new policies (political will)" Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 20.

• 42

  See here for more about the reasoning for this adjustment.

• 43"The organization is engaged in a number of large, multi-country public health initiatives, whose technical dimensions and implementation methods are highly relevant to the proposed APHDI Initiative. These include initiatives on tobacco control, food policy, road safety, data systems, overdose prevention, and environmental health." Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 25.
  
• 44

  To encourage candidness, we have not published the names of the people we spoke with.

• 45

  "Since 2018, Vital Strategies has supported 43 policy changes across 12 countries: Mexico, Brazil, Ukraine, Turkey, Uzbekistan, China, Pakistan, India, Bangladesh, Myanmar, the Philippines, and Indonesia." GiveWell's non-verbatim summary of a conversation with Vital Strategies, August 26, 2020.

  Written case studies sent by Vital Strategies:

  • Ukraine 2007-2016: A case study of tobacco control cooperation and success (unpublished)
  • Case study – Tobacco Taxation in Chad (unpublished)
  • Vital Strategies’ role in global initiative coordination – example of Bloomberg Philanthropies Initiative for Global Road Safety with additional information in Vital Strategies, Road safety policies and population coverage (unpublished)

• 46
  • RESET Alcohol plans to work primarily in four focus countries, at a cost of ~$3.75m per country for three years. See Vital Strategies BOTEC, row "Cost of 3-year campaign in U.S. dollars."
  • The Centre for Pesticide Suicide Prevention, which works on pesticide suicide, is primarily working in three countries at a cost of ~$2.5m per country for three years. See GiveWell, "Centre for Pesticide Suicide Prevention — General Support (January 2021)".
  • Pure Earth, which works on reducing lead exposure, is working in four countries and two Indian states at a cost of ~$8m/6= $1.3m per location for three years. See GiveWell, "Pure Earth — Support for Reducing Lead Exposure in Low- and Middle-Income Countries," 2022.

• 47

  After discussions with Vital Strategies, we excluded:

  • India and Brazil because they have federal government systems, meaning work would likely be at the state-level so using country-level disease burdens may bias our estimate of cost-effectiveness upwards.
  • Russia because our understanding is it has already made substantial progress on alcohol policy.
  • Pakistan and Indonesia because they are majority-Muslim countries with strong norms against alcohol consumption.
  • Ukraine and China because Vital Strategies suggested it was unlikely to be able to make progress in those countries.

• 48

  See GiveWell, Probability of success: alcohol policy for more information.

• 49

  See here. Roughly, we estimate the program would be in the region of 7x as cost-effective as GiveDirectly's cash transfer program (the bar we were using was 8x at the time we made this grant) if its only impact over five years (with a grant extension) was to increase the tax rate on alcohol in one country (weighted by the likelihood RESET Alcohol enters that country) by 10% of price.
  

• 50

  "During the second year, we anticipate specific legislative, regulatory, or executive actions to be developed and the policy enactment process underway, with supportive analytic products, advocacy efforts, media campaigns, and other activities." Vital Strategies, Alcohol Policy for Health and Development Initiative — Proposal May 2021, p. 3.

• 51"On track" for each country is defined as an average of "on track" according to the following four milestones in each country:

  "Year 1 Milestones

  1. Ministry of Finance and other relevant government offices internally endorses raising alcohol excise taxes
     Disappointing: No clear endorsement; ongoing discussions and high-level advocacy; misalignment between ministries
     On Track: General endorsement, tasked Ministry officials to work on details
     Best case: Public endorsement by high-ranking government officials (ministerial announcement, etc
  2. Ministry of Health and other relevant government offices internally identifying and endorsing at least one additional priority policy action from SAFER package
     Disappointing: No clear endorsement; ongoing discussions and high-level advocacy; misalignment between ministries
     On Track: General endorsement, tasked Ministry officials to work on details
     Best case: Public endorsement by high-ranking government officials
  3. Detailed policy plan developed, including relevant economic and epidemiologic analyses, legal analysis, policymaking mechanism identified, etc)
     Disappointing: Outline of plan developed but limited progress on content
     On Track: Analyses and detailed plan well underway, substantial progress on key analytics
     Best case: Detailed plan with accompanying analytics complete
  4. Supporting advocacy underway
     Disappointing: Poor engagement and organizing by lead advocacy organization; misalignment with government priorities
     On Track: Lead advocacy organization fully engaged and aligned with government, network of supporting organizations coming together, public discourse/communications plan developed and underway
     Best case: Robust public discourse in support of policies underway with multiple civil society voices supporting." Email from Adam Karpati, unpublished, November, 30th 2021

  The lead investigator of this grant will decide this based on their judgment, in conversation with Vital Strategies.
  

• 52"On track" for each country is defined as an average of "on track" according to the following four milestones in each country:

  "Year 2 Milestones

  1. Key economic and epidemiologic analyses in support of policy interventions complete
     Disappointing: Limited progress by designated think tank and government analysts
     On Track: Key studies completed or substantial progress (e.g., per capita consumption calculations, price sensitivity estimations);
     Best case: Key studies completed and government institutionalizing new processes for alcohol-related surveillance
  2. Tax policy proposal developed
     Disappointing: Lack of agreement on details of proposal
     On Track: Detailed proposal developed
     Best case: Detailed proposal developed and introduced in relevant legislative/regulatory process
  3. Other alcohol policy intervention developed
     Disappointing: Lack of agreement on details of proposal
     On Track: Detailed proposal developed
     Best case: Detailed proposal developed and introduced in relevant legislative/regulatory process
  4. Supporting policy advocacy underway
     Disappointing: substantial industry interference; lack of commitment from government; poorly organized supporting stakeholders
     On Track: Network of civil society supporters engaged and active; public communications campaign developed with positive public response; “earned media” emerging with positive framing
     Best case: Minimal industry interference; strong stakeholder and public support." Email from Adam Karpati, unpublished, November 30th, 2021

  The lead investigator of this grant will decide this based on their judgment, in conversation with Vital Strategies.